Prenatal Health Care Outcomes Before and During the COVID-19 Pandemic Among Pregnant Individuals and Their Newborns in an Integrated US Health System
Authors: Assiamira Ferrara, Mara Greenberg, Yeyi Zhu, Lyndsay A. Avalos, Amanda Ngo, Jun Shan, Monique M. Hedderson, Charles P. Quesenberry
Journal: JAMA Network Open (2023)

<h3>Importance</h3> The COVID-19 pandemic accelerated the use of telemedicine. However, data on the integration of telemedicine in prenatal health care and health outcomes are sparse. <h3>Objective</h3> To evaluate a multimodal model of in-office and telemedicine prenatal health care implemented during the COVID-19 pandemic and its association with maternal and newborn health outcomes. <h3>Design, Setting, and Participants</h3> This cohort study of pregnant individuals using longitudinal electronic health record data was conducted at Kaiser Permanente Northern California, an integrated health care system serving a population of 4.5 million people. Individuals who delivered a live birth or stillbirth between July 1, 2018, and October 21, 2021, were included in the study. Data were analyzed from January 2022 to May 2023. <h3>Exposure</h3> Exposure levels to the multimodal prenatal health care model were separated into 3 intervals: unexposed (T1, birth delivery between July 1, 2018, and February 29, 2020), partially exposed (T2, birth delivery between March 1, 2020, and December 5, 2020), and fully exposed (T3, birth delivery between December 6, 2020, and October 31, 2021). <h3>Main Outcomes and Measures</h3> Primary outcomes included rates of preeclampsia and eclampsia, severe maternal morbidity, cesarean delivery, preterm birth, and neonatal intensive care unit (NICU) admission. The distributions of demographic and clinical characteristics, care processes, and health outcomes for birth deliveries within each of the 3 intervals of interest were assessed with standardized mean differences calculated for between-interval contrasts. Interrupted time series analyses were used to examine changes in rates of perinatal outcomes and its association with the multimodal prenatal health care model. Secondary outcomes included gestational hypertension, gestational diabetes, depression, venous thromboembolism, newborn Apgar score, transient tachypnea, and birth weight. <h3>Results</h3> The cohort included 151 464 individuals (mean [SD] age, 31.3 [5.3] years) who delivered a live birth or stillbirth. The mean (SD) number of total prenatal visits was similar in T1 (9.41 [4.75] visits), T2 (9.17 [4.50] visits), and T3 (9.15 [4.66] visits), whereas the proportion of telemedicine visits increased from 11.1% (79 214 visits) in T1 to 20.9% (66 726 visits) in T2 and 21.3% (79 518 visits) in T3. NICU admission rates were 9.2% (7014 admissions) in T1, 8.3% (2905 admissions) in T2, and 8.6% (3615 admissions) in T3. Interrupted time series analysis showed no change in NICU admission risk during T1 (change per 4-week interval, −0.22%; 95% CI, –0.53% to 0.09%), a decrease in risk during T2 (change per 4-week interval, −0.91%; 95% CI, –1.77% to −0.03%), and an increase in risk during T3 (change per 4-week interval, 1.75%; 95% CI, 0.49% to 3.02%). There were no clinically relevant changes between T1, T2, and T3 in the rates of risk of preeclampsia and eclampsia (change per 4-week interval, 0.76% [95% CI, 0.39% to 1.14%] for T1; −0.19% [95% CI, –1.19% to 0.81%] for T2; and −0.80% [95% CI, –2.13% to 0.55%] for T3), severe maternal morbidity (change per 4-week interval , 0.12% [95% CI, 0.40% to 0.63%] for T1; −0.39% [95% CI, –1.00% to 1.80%] for T2; and 0.99% [95% CI, –0.88% to 2.90%] for T3), cesarean delivery (change per 4-week interval, 0.06% [95% CI, –0.11% to 0.23%] for T1; −0.03% [95% CI, –0.49% to 0.44%] for T2; and −0.05% [95% CI, –0.68% to 0.59%] for T3), preterm birth (change per 4-week interval, 0.23% [95% CI, –0.11% to 0.57%] for T1; −0.37% [95% CI, –1.29% to 0.55%] for T2; and −0.15% [95% CI, –1.41% to 1.13%] for T3), or secondary outcomes. <h3>Conclusions and Relevance</h3> These findings suggest that a multimodal prenatal health care model combining in-office and telemedicine visits performed adequately compared with in-office only prenatal health care, supporting its continued use after the pandemic.